Last September, Texas Sen. Nathan Johnson (D- Dallas) and Rep. Julie Johnson (D – Dallas) took part in the 2022 North Texas State of Reform Health Policy Conference, where they expressed optimism about their plans to reintroduce Medicaid expansion ahead of this year’s legislative session.
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The state’s regular session ended on May 29th with Medicaid expansion efforts—including Senate Bill 195 and House Bill 652, measures to create a “Live Well Texas” program—failing to pass in their respective chambers.
Sen. Johnson introduced three options for expansion—a state plan amendment, waiver application, and state referendum—before fellow lawmakers, but none of his bills on Medicaid expansion managed to advance out of committee.
While the legislature did raise overall spending on health and human services this session, separate measures to expand Medicaid coverage for specific groups, including working parents, adults with behavioral health disorders, and young adults under the age of 26, all failed to get committee hearings.
In an interview with State of Reform following the end of the regular session, Sen. Johnson expressed frustration at hitting a “brick wall” in efforts to pass expanded public health coverage.
“I honestly don’t know what more to do. We can keep hammering at it—I plan to keep hammering at it—but the idea that we’ll develop a new strategy this time, we’ll go talk to business, law enforcement, admin—we’ve done all of that. I think that strategically all I can do is keep hitting, and hope that [it] eventually falls down.
Eventually leadership will find a way to get past historical opposition to it, and that’s a political question. One of the tactics I will continue to employ [will be] trying to present a way for Republicans who have opposed Medicaid expansion to now support Medicaid expansion without being accused of flip-flopping.”
— Sen. Johnson
Republican opposition to Medicaid expansion has revolved around politics, and the conservative ideological opposition to spending large amounts of public funds on government programs. The Texas Public Policy Foundation, a conservative think tank, again placed stopping Medicaid expansion as one of its top legislative priorities for this year’s session.
Sen. Johnson outlined the social and economic benefits of eligibility expansion in his presentation last fall, which include significantly increased federal matching funds, additional tax credits, and lower crime rates.
Results from a state survey released in February show that three-quarters of Texans (72%) support Medicaid expansion while more than two-thirds (65%) said the state government is not doing enough to ensure access to healthcare for low-income adults.
Rep. Johnson, who before this year’s session shared the optimism that more of her Republican colleagues would support Medicaid expansion, also expressed frustration at the failure to make any political progress on expanding health coverage to more Texans.
“We filed the ‘Live Well Texas’ plan again for comprehensive Medicaid expansion, but there’s just not an appetite in the Republican caucus right now to even have a hearing and discuss it. I think it’s because [Republicans] know if [Medicaid expansion] was actually on the table, it would pass.”
— Rep. Johnson
Texas lawmakers had a $32.7 billion budget surplus to work with this session to expand the Medicaid program.
Texas has the highest rate of uninsured residents in the nation and remains one of 10 states that have yet to expand Medicaid coverage to adults with incomes up to 138% of the Federal Poverty Level under the Affordable Care Act.
Expanding Medicaid to that threshold would bring an estimated $15.3 billion in federal incentives to the state and qualify an additional 1.7 million uninsured Texans for coverage.
Rep. Johnson spoke about the strategies Democrats will focus on in preparation for the next session’s work on Medicaid expansion, which primarily entails continued advocacy among different stakeholders.
“If the pandemic taught us anything, it’s [that] the health of one affects the health of others. [Work on expansion] is just continuing to speak on these issues, continuing to prioritize these issues, and educating voters on how to be healthcare voters, and educating our medical community to be stronger advocates as well. We have to expand the voices of change. We can’t just have the same ones.”
— Rep. Johnson
Rep. Johnson said she will continue to seek bipartisan support in areas of healthcare reform where the state can achieve better outcomes, including Live Well Texas. She believes the legislature made some modest gains in healthcare this session, which include her initiatives eliminating prior authorization burdens for access to prescription drug treatments and expanding the scope of insurance coverage for hearing aids.
A big part of initiatives to expand Medicaid in the state is increasing provider reimbursement rates. The Texas Medicaid-to-Medicare fee index, the ratio of Medicaid to Medicare physician reimbursement for all services, currently stands at 65 percent, which is below the federal average of 72 percent and among the lowest rates in the country.
Sen. Johnson believes the medical community will have to be more forceful in its advocacy for Medicaid expansion to pass.
“There are many institutions and sectors where forceful advocacy is warranted on particular issues. And those constituencies are timid in their statements for fear of losing or going backwards in other areas. And I definitely think we’re seeing that in the healthcare space.”
— Sen. Johnson
Sen. Johnson feels that with the failure to expand Medicaid and the projected loss in coverage, the state has lost ground on improving healthcare access.
The latest figures on the national Medicaid redetermination processs show more than 1.5 million Americans and counting have lost coverage, over 70% of whom lost coverage due to procedural reasons. Texas was not included in that data set because its redetermination process started earlier this month, but it remains to be seen what the coverage loss impact will look like as the unwinding unfolds.
“We are not funding the people that we could. We are not drawing down federal dollars that we could. We are making our state more sick, less productive, and more expensive than we have to be.
There are solutions out there. Even these small-scale things [introduced this session] could be partial solutions. We just can’t get them done. And for something so patently beneficial as Medicaid expansion—that we can’t do it, that we’re still stuck in politics that is beyond stale—it does frustrate me immensely.”
— Sen. Johnson
Despite those frustrations, the two lawmakers say they will look at ways to reintroduce expansion legislation next session while watching how Medicaid redetermination unfolds.
Sen. Johnson hopes the collective progress made on Medicaid reforms over the past decade and the available federal information about the impacts of the federal program will convince Republicans to take action.
“[Medicaid is] a different system [than it was ten years ago]. At the time, [Texas was] fee-for-service. We are now [a managed care organization]—we are one of the most efficient MCOs in the country.
It would be easy for me, [if I were] a conservative Republican, to say: ‘I’ve got a world of information—this is no longer a leap of faith—I have empirical evidence across the state.’ The stability of the [Medicaid] program is beyond question, as three-quarters of the nation now has [Medicaid] woven into their healthcare systems and their economies … Medicaid now works. I did not want to expand a broken federal system, but I now have state control and I can do this through a state plan to the new and improved system that I’ve created. It is time for me to bring home my federal tax dollars.”
— Sen. Johnson